Seizure

Steps

1. Turn the patient onto their side and lower the gurney. Protects the airway if they vomit, and stops them falling. Do not restrain them and do not put anything in their mouth.
2. Note the time the seizure started. Everything after this is timed from here. Prolonged seizures and repeated ones are what damage the brain, so the duration is what decides how aggressive the team becomes.
3. Give oxygen and call the provider. Say how long it has been going on when you call.
4. Check a point-of-care glucose. Hypoglycemia causes seizures and is fixed in seconds. Rule it out before looking any further.
5. Give a benzodiazepine — first line. IV lorazepam if there is a line: it starts fast and its anti-seizure effect lasts. If there is no IV, give IM midazolam — it works faster than IM lorazepam, so do not lose time chasing access first.
6. Give levetiracetam (Keppra) IV — second line. Phenytoin and valproic acid are alternatives, but Keppra is what is usually used. Most seizures stop by this point, after a benzodiazepine and Keppra.
7. If it is still going, prepare for intubation. Ongoing or repeated seizures need more than the room can give: propofol and midazolam infusions, both of which have anti-seizure properties. Phenobarbital may also be used.
8. Treat the underlying cause. Hypoglycemia → dextrose. Hyponatremia → hypertonic saline. Not taking their medication → a loading dose. A brain bleed → down that pathway. An infection → antibiotics.
9. Put seizure precautions in place. Padded side rails, gurney at its lowest, and the patient in view of the nursing station if you can manage it.
10. Ask the provider now what to give if it happens again. Medication and dose, agreed before the next one — not during it.
11. If they came in post-ictal, monitor and chart their progress continuously. Confusion that is clearing is a different picture from confusion that is not.

Notes

Timing is the whole thing: a seizure that stops on its own is a very different patient from one that does not, and the difference is measured in minutes. Get the benzodiazepine in without waiting for a line — IM midazolam exists for exactly that. Treating the cause runs alongside stopping the seizure, not after it. Doses and agents follow the Neurological Emergencies lecture; confirm them against your own facility protocol and the provider order.